- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.45 / $1,157.78 / $2,500.00
| Facility | | $267.45 | $1,157.78 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.21 / $913.06 / $1,212.24
| Professional | | $253.21 | $913.06 | $1,212.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.34 / $748.21 / $2,607.83
| Professional | | $527.34 | $748.21 | $2,607.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $459.52 / $459.52 / $459.52
| Facility | | $459.52 | $459.52 | $459.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.73 / $807.65 / $2,656.08
| Professional | | $325.73 | $807.65 | $2,656.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.82 / $622.84 / $2,469.04
| Facility | | $329.82 | $622.84 | $2,469.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.07 / $2,621.35 / $7,706.96
| Professional | | $1,282.07 | $2,621.35 | $7,706.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.07 / $2,214.48 / $3,036.28
| Professional | | $1,282.07 | $2,214.48 | $3,036.28 |